Medi-Cal Provider Education Notice 07/08/2016
Attention Medi-Cal Network Provider,
Below & attached please find summary reviews for these important Medi-Cal programs and services. These summaries are
providing just an overview of these services and requirements that you must be aware of. To review and learn more
regarding any and all of these program requirements, please go onto www.regalmed.com (see Provider tab), or call our
Provider Assistance Line at 888-787-1712. To reach the on-call staff member after hours, call 818-654-6400, Option 9.
SPECIAL BENEFITS AND COMPLIANCE
WHAT YOU NEED TO KNOW
PREVENTIVE SERVICES
Initial Health Assessment/Individual
Health Education Behavior Assessment/
Staying Healthy Assessment
Initial Health Assessments (IHA) are a requirement for all new Medi-Cal patients. To
make it easy for you, we send out a letter to all your new patients who need their
IHA completed. Please note: Patients who are 18 months or older must receive
an IHA within 120 days and patients less than 18 months old must receive an
IHA within 60 days. Here are the assessments broken down by age group:
For Children:
•
Early and Periodic Screening, Diagnostic and Treatment (EPSDT) benefits
provide early detection and preventive care for eligible children under the
age of 21. As a provider, you are required to provide this screening service
as part of the patients initial health assessment screening or when medically
necessary. For more information, visit: http://www.dhcs.ca.gov/services/
Pages/EPSDT.aspx
•
Child Health Disability Prevention (CHDP) program provides complete health
assessments for the early detection and prevention of disease and disabilities
for low-income children and youth. A health assessment consists of a physical
examination, developmental assessment, nutritional assessment, dental
assessment, vision, and hearing tests, and tuberculin test, laboratory tests,
immunizations, health education and referrals for any needed diagnosis and
treatment. For more information, please visit: http://www.dhcs.ca.gov/
services/chdp/Pages/ProgramOverview.aspx
For Adults:
•
Screening and Brief Intervention, Referral to Treatment (SBIRT): As a
provider you are required to provide screening as part of the patient’s initial
health assessment or when medically necessary. Your patient needs to
be screened based on the SHA (Staying Healthy Assessment). For more
information, visit: http://www.dhcs.ca.gov/formsandpubs/forms/Pages/
StayingHealthyAssessmentQuestionnaires.aspx
Medi-Cal Provider Education Notice (Cont’d) 07/08/2016
SPECIAL BENEFITS AND COMPLIANCE
WHAT YOU NEED TO KNOW
What You Need to Know: Audit Requirements
You must document attempts that demonstrate unsuccessful efforts to contact
a patient to schedule an IHA appointment in the patient’s health record.
Documentation will be considered evidence in meeting this requirement.
Requirements for missed or broken appointments are as follows:
• First Attempt – Phone call to patient (or written letter if no telephone).
If patient does not respond, then;
• Second Attempt – Phone call to patient (or written letter if no telephone).
If patient does not respond then;
• Third Attempt – Written letter.
For details, refer to the FAQ for IHA on www.regalmed.com under Provider
Resources or within REA under Medi-Cal & News links.
COORDINATED SERVICES
Durable Medical Equipment
Medi-Cal patients are provided durable medical equipment if medically necessary.
Medi-Cal covers medically necessary equipment when it “is appropriate for use
in or out of the patient’s home” (Title 22, CCR, and Section 51160). For manual
wheelchair prescriptions, an evaluation is required by a licensed provider
before a manual wheelchair can be ordered.
What You Need to Do:
Visit www.regalmed.com under Provider Resources or within REA under
Medi-Cal & News links for sample evaluation form and complete the
authorization/claims process for durable medical equiment.
Transportation Services
Regal may authorize transportation for Medi-Cal patients if the services will allow
smooth continuity of care for the patient at Regal’s discretion. Please note that
transportation services are coordinated differently by health plan.
What You Need to Do:
Submit an authorization request, which must be accompanied by
transportation prescription at www.regalmed.com under the Provider
Section and our internal case management team will coordinate all
transportation requests.
Continuity of Care (COC) Services
For all Medi-Cal patients transitioning to Medi-Cal Managed Care from Medi-Cal
Fee For Service (FFS), patients are allowed the option to continue treatment
for up to 12 months with an out-of-network Medi-Cal provider. These eligible
beneficiaries may require continuity of care for services they had been receiving
through Medi-Cal FFS.
What You Need to Know:
1. Regal must be able to determine that the beneficiary has an ongoing
relationship with the provider (self-attestation is not sufficient to provide proof
of a relationship with a provider);
2. The provider must be willing to accept Medi-Cal FFS rates;
3. The provider must meet Regal’s applicable professional standards and has no
disqualifying quality of care issues.
For more information, call the provider assistance line at 888.787.1712.
Medi-Cal Provider Education Notice (Cont’d) 07/08/2016
SPECIAL BENEFITS AND COMPLIANCE
WHAT YOU NEED TO KNOW
Managed Long Term and
Support Services
Long Term Services and Support (LTSS) help elderly individuals and/or individuals
with disabilities with their daily needs for assistance/improvement of their quality
of life. Examples include assistance with bathing, dressing and other basic
activities of daily living and self-care, as well as support for everyday tasks such as
laundry, shopping and transportation. LTSS is provided over an extended period,
predominantly in the patient’s home and in the community, but also in facilitybased settings such as nursing facilities.
These services are categorized into four groups:
•
Multipurpose Senior Services Program (MSSP)
•
In Home Support Services (IHSS)
•
Community-Based Adult Services (CBAS)
•
Long Term Care
How to Coordinate Services:
Please visit www.regalmed.com for the details of the coordination of LTSS
services. For assistance in coordinating care for Medi-Cal patients, provider
may send an authorization request. Our case management department will
help with the coordination of services.
SERVICES REQUIRING NO PRIOR AUTHORIZATION
Medi-Cal Sensitive Services
Medi-Cal Sensitive Services are a covered benefit and do not require prior
authorization for both in and out of network provider services. The list of MediCal sensitive services are as follows:
•
Sexually transmitted diseases
•
Family planning services for network or out of plan providers
•
Abortion services (physician provided services)
•
Sterilization and Informed consent
•
Human Immunodeficiency virus (HIV) Testing and Counseling
•
Minor Consent Services
•
Hospice Services
What You Need to Know:
By law, sterilization requests do not require authorization, but require an
informed consent form be obtained from patient. Therefore, all sterilization
claims must be accompanied by the sterilization consent form dated and signed
by both the provider and the patient 30 days prior to the date the sterilization
service was rendered.
Medi-Cal Provider Education Notice (Cont’d) 07/08/2016
SPECIAL BENEFITS AND COMPLIANCE
WHAT YOU NEED TO KNOW
CARVE OUT SERVICES
California Children’s Services
Program (CCS)
California Children’s Services (CCS) is a state funded Medi-Cal program for
children who are under 21 years of age and meet established criteria. Once a
Medi-Cal patient’s condition is accepted as a CCS eligible diagnosis, services are
carved out to the CCS program by Regal’s Medi-Cal CCS department.
Criteria to qualify for CCS services:
1.
2.
Patient must have a health problem that is covered by CCS
Patient must be a resident of California and has one of the following:
•
Family income of $40,000 or less
•
Out-of-pocket medical expenses expected to be more than 20 percent of
family’s adjusted gross income
•
A need for an evaluation to find out if there is a health problem covered
by CCS
•
Was adopted with a known health problem that is covered by CCS
•
A need for the Medical Therapy Program
•
Medi-Cal, with full benefits
What to Know and How to Access More Information:
Transplant Procedures
•
All CCS procedures must be administered by a CCS Panel provider.
•
All CCS referrals should be accompanied by detailed progress/visit notes
and also Lab results if applicable to ensure the successful approval of the
CCS request.
•
A list of qualifying CCS diagnoses is available at www.regalmed.com
under Provider Resources or within REA under Medi-Cal & News links.
Transplant procedures are a covered benefit for Medi-Cal patients. Transplant
requests are categorized in two ways based on the payer of the services:
•
•
Kidney and cornea transplants
All other major organ transplants
Regal evaluates all potential transplant authorization from the provider once the
authorization is approved:
For kidney and cornea transplants, the patient’s medical group will pay for the
services and for all other major organ transplants, the Medi-Cal program pays
for the services. This means that all patients who are approved for a major organ
transplant except kidney and cornea get reassigned (disenrolled) back to the
Medi-Cal fee for service program after evaluation and approval of transplant services.
Please note: The transplant center physician must submit a Treatment
Authorization Request (TAR) to the San Francisco Medi-Cal Field Office (For
adults 21 years and older) to initiate the reassignment of the potential transplant
patient back to the Medi-Cal program. Once the Medi-Cal program approves the
request, the transplant center physician can perform transplant services.
Medi-Cal Provider Education Notice (Cont’d) 07/08/2016
SPECIAL BENEFITS AND COMPLIANCE
WHAT YOU NEED TO KNOW
Transplant Procedures (Cont’d)
San Francisco Medi-Cal Field Office
185 Berry Street, Suite 290
San Francisco, CA 94107
(415) 904-9600
For children under 21 years of age, Regal will coordinate the approval of the TAR
with California Children’s Services Program.
What You Need to Know:
All transplant procedures and Workup needs to be completed at a DHCS
approved transplant center. Regal will coordinate all referrals and
authorization to ensure this.
See the Medi-Cal Transplant FAQ for complete details of the coordination of
transplant services at www.regalmed.com under Provider Resources or
within REA under Medi-Cal & News links.
Dental Services
Dental Benefits are carved out to Denti-Cal with the state. Refer patients to the
Denti-Cal program by calling: 1-800-322-6384 for more information.
Vision Services
Vision services are provided by the patient’s Health Plan. We recommend that the
patient contact his/her health plan for coordination of services. Health plan
name is located on the patient’s Medi-Cal ID card.
Mental/Behavioral Health Services
Medi-Cal beneficiaries with serious mental health needs that cannot be met
within a primary care physician’s scope of practice receive specialty mental
health services and support that are administered by the County Health Office or
sometimes carved out vendors through the health plan.
How to Refer Patients:
It is best to refer all cases to our Behavioral Health Team by submitting an
authorization at www.regalmed.com, using your provider access
express account.
Key Contact Information
Regal Medical Group Provider Portal: www.regalmed.com
After hours contact Information: 818-654-6400, option 9
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